Facet joint syndrome: from diagnosis to interventional management
Low back pain (LBP) is the most common pain syndrome, and is an enormous burden and cost generator for society. Lumbar facet joints (FJ) constitute a common source of pain, accounting for 15–45% of LBP. Facet joint degenerative osteoarthritis is the most frequent form of facet joint pain. History and physical examination may suggest but not confirm facet joint syndrome. Although imaging (radiographs, MRI, CT, SPECT) for back pain syndrome is very commonly performed, there are no effective correlations between clinical symptoms and degenerative spinal changes. Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as neurolysis, by radiofrequency or cryoablation. The purpose of this review is to describe the anatomy, epidemiology, clinical presentation, and radiologic findings of facet joint syndrome. Specific interventional facet joint management will also be described in detail.
• Lumbar facet joints constitute a common source of pain accounting of 15–45%.
• Facet arthrosis is the most frequent form of facet pathology.
• There are no effective correlations between clinical symptoms, physical examination and degenerative spinal changes.
• Diagnostic positive facet joint block can indicate facet joints as the source of pain.
• After selection processing, patients may benefit from facet joint neurolysis, notably by radiofrequency or cryoablation.
KeywordsLow back pain Facet joint Block Neurolysis Radiofrequency Cryoablation
Low back pain
Medial branch of the dorsal rami
Magnetic resonance imaging
Superior articular process
Single-photon emission computed tomography
Chronic low back pain is one of the most common pain syndromes and represents an enormous burden and cost generator for society . Lumbar facet joints (FJs) constitute a common source of pain and remain a misunderstood, misdiagnosed and improperly treated pathology . Facet osteoarthritis is the most frequent form of facet pathology . Although imaging for back pain syndrome is very common (radiographs, MRI, CT, SPECT), there is no effective correlation between clinical symptoms and degenerative spinal changes , with some imaging findings that may, in specific cases, appear irrelevant to the clinical setting. Clinical facet joint syndrome is defined as a unilateral or bilateral back pain radiating to one or both buttocks, sides of the groin, and thighs, and stopping above the knee . However, in some cases, patients’ symptoms in the setting of low back pain may lack specificity, as facet joints may mimic the pain caused by herniated discs or compressed roots. History and physical examination may suggest, but not confirm FJs as the source of pain . A diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain , but the rate of false positives remains high. After conservative management failure, these patients may benefit from articular steroid injections  and/or specific interventions to eliminate facet joint pain such as neurolysis . Radiologists play an important role in the management of back pain, as imaging of spinal disorders has become one of the keys to better patient management. Moreover, interventional radiology has become a keystone of facet joint management, as both a diagnostic and a therapeutic tool. Therefore, this review aims to provide the radiologist with specific information on facet joint epidemiology, anatomy and physiopathology, and its implication in chronic low back pain. Furthermore, the authors describe the essential knowledge of facet joint imaging modalities along with a detailed description of existing interventional management.
Chronic and recurrent pain has been defined as a specific health care problem and is considered a disease in its own right . A recent survey showed a high prevalence of chronic pain of moderate to severe intensity in adult Europeans, affecting the quality of their social and working lives and is therefore a major health care problem in Europe . Low back pain (LBP) is one of the most common pain syndromes and is an enormous burden and cost generator for society. The high health care costs may be attributed to multiple factors, including lack of an accurate diagnosis , imaging overuse, unwarranted surgery and working stoppages. LBP is responsible for functional limitations and causes difficulty in performing common daily life tasks, especially among the elderly . Therefore, LBP is the most expensive disease in industrialized countries, as has been reported in Germany at a total cost of 48.960 billion euros per year . In the USA, the prevalence of LBP is reportedly between 15 and 45% according to cross-sectional studies . Most spinal structures may be source of LBP, including intervertebral discs, FJs, sacroiliac joints and nerve roots, and may be accessible to diagnostic tests including imaging. Some disorders, particularly disc-related impairments, are reasonably easily diagnosed and lead to definitive treatments. However, discogenic LBP without disc herniation, lumbar FJ, and sacroiliac joint pain are difficult to diagnose with imaging only . The literature focuses on intervertebral discs as the source of LBP; however, FJ pain also seems to play a major role in generating LBP . Among LBP patients, there are wide discrepancies in the reported prevalence of FJ pain. Reviews implicate FJs as the primary pain generator in 10–15% of young adult patients with chronic LBP and higher in older populations (15% among injured workers, 40% in older population without pre-existing trauma, 45% in a more heterogeneous population) . Controlled diagnostic studies have shown a prevalence of lumbar FJ pain of 27–40% in patients with chronic LBP .
Anatomy of facet joints (FJs)
Etiologies of facet joints
Degenerative process (Fig. 2)
Spondylolisthesis (Fig. 3)
Septic facet arthritis (Fig. 4)
Rheumatoid arthritis and ankylosing spondylitis, which are seronegative spondyloarthropathies, may also involve the lumbar FJs, as FJs are synovial joints .
Clinical presentation and pain patterns
Imaging findings (Table 1)
X-ray imaging: Radiographs and computed tomography (CT)
Main imaging findings in various imaging modalities
AP, lateral (isthmus profile) and oblique views (“Scottie dog”)
Highest contrast between bony structures and adjacent soft tissue
Active synovial inflammation,
Adjacent bone edema
Fat saturation technique ± Gadolinium injection
99mTc labelled bisphosphonates
Hyperemia associated with bone remodelling
Joint space narrowing
Subchondral sclerosis and erosions
Calcification of the joint capsule
Hypertrophy of articular processes
Vacuum joint phenomenon joint effusion
Facet joint effusion
Subchondral bone edema
Enhancement of the FJ rim (synovitis)
Wraparound bumper osteophyte formation
Increased uptake (nonspecific)
Magnetic resonance imaging (MRI) (Fig. 6)
Single-photon emission computed tomography (SPECT)
Imaging classification of facet joint osteoarthritis
Two classifications of FJ degeneration are recommended for clinical use. Radiographically, Pathria’s classification classifies FJ arthropathy as well: Facets with joint space narrowing are classified as grade 1, facets with narrowing and sclerosis or hypertrophy as grade 2, and facets with severe degenerative disease encompassing narrowing, sclerosis, and osteophytes as grade 3 . Standard radiographs (Meyerding or Taillard classification)  also evaluate motion-related abnormalities in flexion or extension, and assess instability in cases of spondylolisthesis, thanks to dynamic studies. In the setting of degenerative spondylolisthesis, a weight-bearing lateral flexion-extension radiograph is most effective for grading spondylolisthesis and may be needed in addition to MRI and CT imaging. Anteroposterior translation of more than a few millimetres is suggestive of lumbar spine instability in the sagittal plane, which in the appropriate clinical setting may require surgical arthrodesis. In addition to Pathria’s classification, Weishaupt’s grading scheme, based on the agreement between MRI and CT imaging, has been proposed. Facets were again graded from 0 to 3 depending on the degree of joint space narrowing, hypertrophy, sclerosis, and osteophyte formation. The authors recommended against the routine use of CT imaging in the presence of an adequate MRI scan . Fujiwara et al. is credited with developing the standard MRI-based classification system for lumbar FJ osteoarthritis. An additional grading system for foramen stenosis, caused by disc and FJ degeneration can be used as well, based on the depiction of the foraminal components: nerve, vessels and fat . First stage, the non stenotic stage: no modifications depicted. Second stage corresponds to stenosis without evidence of root compression. Third stage, compression of the spinal nerve in the intervertebral foramen caused by either intervertebral disc, flaval ligament or osseous stenosis. In this stage, the content of the foramen is not well identified. A grading scale has also been proposed for lumbar canal stenosis as follows : A) cerebro-spinal fluid (CSF) is clearly visible inside the thecal sac, but its distribution is inhomogeneous. B) Some CSF is still present, giving a grainy appearance to the thecal sac. The rootlets occupy the whole of the dural sac, but they can still be individualized. C) the dural sac demonstrates a homogeneous grey signal with no CSF. No rootlets can be recognized. D) In addition to no rootlets being recognizable, there is no epidural fat posteriorly.
There is currently no consensus on how best to evaluate lumbar FJ osteoarthritis with imaging. It has been reported that in clinical practice, imaging findings of degenerative abnormalities (including radiographs, MRI, CT, SPECT) have been assumed to be associated with nonspecific low back pain . Radiographic changes secondary to osteoarthritis are equally reported among symptomatic and asymptomatic patients. Radiological investigations report a poor correlation between clinical symptoms and degenerative spinal changes . Therefore, the role of FJ imaging in patient with LBP is still debated. The interest of imaging often lies in its ability to rule out differential diagnosis, commonly referred to as “red flag indications”, rather than to prove a symptomatic condition. Red flag indications are intended to represent the potential for life or limb threatening conditions (suspicion of aortic aneurysm or dissection, neoplasm, infection, cauda equina syndrome, fracture, motor weakness). Advanced diagnostic imaging of the symptomatic level is appropriate and/or work-up for a non-spinal source of spine pain .
First-line therapy consists in conservative multimodal management such as pain medication (acetaminophen, nonsteroidal anti-inflammatory drugs, muscle relaxants, antidepressants), physiotherapy, acupuncture, and, if necessary, psychotherapy .
As mentioned above, because radio-clinical correlation is not reliable in patients with LBP, the diagnostic and therapeutic role of interventional procedures targeting the FJ have been reported in chronic spinal pain in patients who have failed conservative management . Whatever the technique used, it has been shown that the physician’s attitude seems to affect the clinical outcome of a procedure by a hetero-suggestion phenomenon, with better results . Imaging guidance has shown to both to increase technical and clinical efficacy and reduce potential complications . Common complications of FJ procedures include: hemorrhagic, infectious complications, and vasovagal syncope .
Because no clinical features or diagnostic imaging studies can determine whether an FJ is painful or not, controlled blocks are the only reliable tool in the diagnosis of FJ pain as a cause of LBP . Diagnostic blocks of nervous structures that are suspected to generate pain can be performed to evaluate the role of the target structure in the painful syndrome . However, several debates exist on the technique and the definition of the performed block:
The degree of the relief that should occur
Bogduk defined specific criteria for an optimal selection as an anatomically accurate block under guidance with ideally complete relief of pain following an MBDR block. Manchikanti et al. defined at least an 80% reduction of pain and the ability to perform previously painful movements . More liberal criteria have also been reported, such as greater than 50% relief of pain .
The target of the block (Fig. 8)
The number of blocks and the levels which should be targeted
A definitive diagnosis of FJ mediated pain may require blocks at two separate sessions. When performing a single-level block only, there is a high false-positive rate (30–45%). Some authors have therefore advocated the performance of repeated blocks . Cohen et al. showed a success rate of lumbar FJ radiofrequency (RF) denervation patients of 39% after a single block and 64% after a double block . Because of the dual nerve supply of FJs, at the same level and the level above, diagnostic blocks should be performed with a minimum of two levels to block a single joint .
In the majority of the reported studies, FJ injection include long acting corticosteroids (anti-inflammatory and antiedematous effect, immunosuppressive action and inhibition of neural transmission within the C fibres) and local anesthetics . FJ can be infiltrated with intra-articular, periarticular and medial branch injections. Due to the presence of inflammatory mediators into and around degenerative FJ, short- to intermediate-term pain relief should occur after steroids injections. However, discrepancies persist in the literature about the efficacy of steroids for FJ pain . Although intra-articular injections (with or without steroids) have traditionally been used in the diagnosis of FJ pain, a controlled trial by Lilius et al. reported no outcome differences between intra- and periarticular injections . European guidelines do not recommend the use of intra-articular steroids in management of chronic LBP .
Main characteristics of the denervation procedure
Tissular heating by friction
T > 45 C°
Decompression of CO2 or N20
T > −20 C°
Possibly longer effect
Technique described in more detail
Wider range of needles available
Less tissue damage
Technically easier (bigger lesion)
More tissue damage
Technically more challenging
Duration of effectiveness less assessed
Larger probes and coaxial needles
Not widely used in this indication
Radiofrequency ablation (RFA) (Fig. 9)
Bogduck et al. underlined the importance of patient selection and the use of a properly performed technique . Appropriate technique is described in the ISIS guidelines  where emphasis is made on the electrode placement: parallel to the target nerve in order to achieve denervation along a substantial length of the targeted nerve . These considerations seem more important to take into account with the RF technique than with CN, where circumferential lesions are less extensive than with cryoprobe . RF probes produce transverse lesions around the electrodes, but little lesioning at the needle tip. Perpendicular placement may miss the targeted nerve . Moreover, operators should not rely on single placement of the electrode, and multiple placements may be required in order to cover all possible variations of the nerve .
In a prospective study, Dreyfuss et al. showed that under these conditions some 60% of patients could expect at least a 90% reduction in pain, and 87% could expect at least 60% reduction lasting 12 months . In Kessinger et al.’s study, conducted in patients with minor degenerative spondylolisthesis, 60% of patients sustained at least 80% pain relief lasting at least 12 months; 80% sustained at least 60% relief . Several controlled studies confirmed this trend [69, 84, 85, 86, 87], with a mean decrease of 2–3 points on a visual analogue scale vs control groups. RF complications are uncommon (1% incidence), of limited duration and minor in nature . Potential side effects include painful cutaneous dysesthesias or hyperesthesia increased pain due to neuritis, neuroma formation, and deafferentation pain. Unintentional damage to a spinal nerve causing a motor deficit, is also a complication . Sensory and motor stimulation during the procedure may help to avoid this complication .
Cryoneurolysis (CN) (or Cryoneuroablation or Cryoanalgesia) (Fig. 10)
As with RFA, the success of cryoneurolysis is dependent on patient selection and accurate probe placement, which should follow the same guidelines described by the ISIS. The extent and duration of the effect is therefore a function of the degree of cold obtained and the length of cold application . In contrast to RFA, a tangential approach of the probe is not essential . Minimal, if any, sedation should be used, as the patient must be conscious to respond to sensory and motor stimulation . Moreover, intra-procedural pain in CN appears to be tolerable .
Lloyd proposed CN as superior to chemical neurolysis . However, CN technique has been described as less accurate than RF. The lasting effect compared to RF also seems unclear. No studies comparing CN and RFA in FJ pain management are available to date. Three recent prospective studies [42, 92, 93] showed a reduction of pain at 6 weeks and 3 and 6 months, with a 50% pain decrease. A recent retrospective study by Wölter et al. in 2011 confirmed this trend . Advantages of CN include less tissue damage, less risk of neuroma or neuritis, and a larger denervation area at the needle tip [91, 94].
This technique requires the administration of a chemical agent able to destroy neural structures (protein denaturation)  involved in the perception of pain to promote long lasting analgesia. The size of the lesions varies according to the concentration, and therefore the quantity. The two neurolytic agents most widely used in the treatment of chronic pain are phenol and alcohol, producing a block that lasts 3–6 months . Major drawbacks with the use of these agents include: necrosis of surrounding tissue, neuritis, and uncontrolled diffusion (83). Furthermore, these powerful neurolytic agents may induce sequelae in the axonal membrane, which might explain cases of painful paresthesia observed several months following a neurolytic block: this is known to be deafferentation pain sequelae . These techniques are also associated with neuroma formation .
The neurolytic effects of ethyl alcohol at a concentration greater than 50% are well known, but higher concentrations (95–100%) are required for nerve destruction to be permanent . Alcohol is extremely irritating to both neural structures and surrounding tissues, causing pain, burns, and local hypersensitivity. Alcohol neurolysis usually causes severe, intense pain, which quickly disappears. Alcohol is associated with a higher rate of neuritis than phenol .
As with alcohol, neurolysis depends on the concentration used: the efficacy of 3% phenol in saline is comparable to that of 40% alcohol. Phenol is responsible for a transient local anesthetic effect (between 5 and 20 weeks). Aqueous phenol is easy to use, with a low potential of diffusion, and does not cause violent pain on injection .
Facet joint denervation: How to do it?
The following criteria should be noted prior to the procedure: history of back pain surgery, description and radiation of pain, mean duration of pain, pain intensity on a numerical pain scale (0–10). Despite the lack of specificity, a physical examination should be performed. Prior imaging studies should be analysed and red flags should be ruled out.
As physical and neurologic examination do not identify symptomatic FJs, and structural findings of FJ osteoarthritis on imaging are not predictive of FJ pain origin, FJs targeted for blocks are chosen based on a combination of clinical and imaging data. Indeed, FJ level can be deduced by comparing the patient’s pain to FJ pain referral maps, T2WI MRI hyperintensity, gadolinium enhancement or increased uptake on SPECT, which may help to identify painful joints.
This procedure can be done under fluoroscopic or CT guidance. Our practice is to use CT guidance and medial branch block. The patient is placed in prone position. An initial, non-enhanced planning CT is performed from the subsequent level in order to determine target and the safest needle pathways. The skin entry point is marked, and a local skin scrub is performed. Needle progression (22G) is performed on axial view under CT guidance (oblique view in case of fluoroscopic guidance) until the needle tip artefact is located at the defined target (at the same level and the level above). The tip of the needle should be placed in the angle formed by the transverse process and at the neck of the medial aspect of the superior articular process in case of L1–4 level or midway between the upper end and middle of the ala of the sacrum at L5–1 level. Diluted iodinated contrast is injected (1 mL) in order to control accurate needle positioning. A mixture of fast and slow acting anesthetic (1 mL mixture of lidocaine hydrochloride 1%, and of ropivacaine hydrochloride 2 mg/mL). Patients are then asked to report pain relief in the following 12 h, both by self-reported improvement (percentage of pain decrease) and VAS score.
All patients should be followed up by physicians in the interventional radiology unit to assess the efficacy and possible complications with the same criteria. Because of a high false-positive rate, in cases of primary block test failure, this test should be repeated before any denervation procedure. Repeated infiltrations may be proposed in case of contraindications or refusal of denervation procedure. Neurolysis may also be repeated.
The results of FJ blocks to predict lumbar surgical outcomes and surgical therapies including arthrodesis for degenerative FJ disorders are discouraging . There is no convincing evidence to support any surgical intervention for FJ degenerative pain. In case of spondylolisthesis, pain relief may be obtained with arthrodesis when interventional management fails, but there are currently no guidelines available. In most cases, non-operative treatment should be attempted before surgical management. Some suggest that the optimal surgical management is a decompressive lumbar laminectomy in patients with grade I or II. On occasion, for those with foraminal/far lateral pathology at the level of the listhesis, patients may require additional non-instrumented or instrumented lumbar fusions . Although there currently is no consensus, FJ neurolysis may be used as a therapeutic tool in cases of surgical management failure on low back pain relief.
Other interventional treatments
Other more recent techniques or imaging guidance have been described in the literature, but will need further assessment. Wu et al. recently compared the effectiveness and safety between autologous platelet-rich plasma (PRP) and local anesthesia/corticosteroid in intra-articular injection for the treatment of FJ syndrome. They showed that prone autologous PRP presented a superior efficacy with longer duration . An observational retrospective study of 86 patients by Kirchner et al. confirmed this trend .
Iwatsuki et al. performed laser radiation of the dorsal surface of the facet capsule in 21 patients and reported greater than 70% pain relief for at least 1 year in 81% (17 patients) . Feasibility and safety of MRI-guided focused ultrasound ablation of the lumbar medial branch nerve has been shown in a swine model and thermal necrosis was confirmed .
Because chronic low back pain of facet joint pain origin represents a major health care problem, diagnosis and management of such a high prevalent condition as facet joint syndrome is a major socioeconomic burden. Because of the ability of facet joint pathology to mimic spine root compression, the low specificity of FJ syndrome and inefficient use of lumbar imaging, it appears as a misunderstood, misdiagnosed and improperly treated pathology. Facet joint-related anatomical, clinical and radiologic knowledge is essential for successful facet joint syndrome management. Diagnostic blocks are a keystone of facet syndrome diagnosis. If diagnostic blocks of the nerves that supply specific facet joints relieve the patient’s pain, denervation procedure lesioning of the same nerves can be offered to provide prolonged benefit. The role of the radiologist is essential in the management of these patients, and radiologists should embrace all aspects of facet joint pain management, from diagnosis—enabled by high-performance modalities available—to interventional management. The radiologist can therefore play an active role in the difficult task of alleviating patients’ chronic low back pain of facet joint origin.
Compliance with ethical standards
Conflict of interest
The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.
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